epilepsies secondary to defined mechanisms - bhatt 10-12-13 · tumor pathology and seizures •...

Epilepsies Secondary to

Defined Mechanisms

Amar B. Bhatt, M.D.Assistant Professor of Neurology

Dept. of Neurology, Adult Epilepsy Division

October 13, 2013

Disclosures

• No financial disclosures.

• Will discuss non-FDA approved (off-label)

treatments.

Objectives

• Autoimmune Epilepsy

• Brain Tumors and Epilepsy

• Malformations of Cortical Development

• Post-traumatic Epilepsy

• Stroke and Epilepsy

Autoimmune Epilepsy

Sources:

Irani et al, Curr Opin Neurol, 2011

McKeon and Pittock, Acta Neuropathol, 2011

Quek et al, Arch Neurol, 2012

Britton, AES Annual Meeting, 2012

Autoimmune Epilepsy Overview

• These are not zebras!

• Seizures + supporting findings

– typical presentation is limbic encephalitis

– strongly suspect in new-onset refractory epilepsy,

or new-onset status epilepticus

Supporting Findings

• Clinical signs– encephalopathy

– amnestic syndrome

– cognitive decline

– personality changes

– psych features (e.g., psychosis, catatonia, agitation)

– movement disorder

• Medical history– other autoimmune stigmata (type 1 diabetes, thyroid

disease, celiac disease, B12 deficiency)

– history of cancer (or strong risk factors for cancer)

Workup

• MRI with contrast

– tends to be normal

– may show edema or T2 hyperintensity in temporal lobes or limbic structures

• CSF usually normal (incl. oligoclonal bands)

• EEG findings are variable

– may show focal or generalized seizures

– may have nonspecific findings

– “extreme delta brush” in NMDA-R antibody

Adapted from Schmitt et al, Neurology, 2012

Workup

• Divide antibodies into cytoplasmic (onconeural) vs. cell membrane

– onconeural are more often paraneoplastic

– cell membrane are more often responsive to immunotherapy

• Cancer screening

– PET-CT brain and body

– select cases – testicular ultrasound, colonoscopy, mammogram, prostate or gynecologic exam

Antibody Associated Cancer Symptoms

(other than seizures / limbic encephalitis)

ANNA-1 Small cell carcinoma Brainstem encephalitis, autonomic or

sensory neuropathy

Ma1, Ma2 Testicular Brainstem encephalitis

CRMP-5 Small cell carcinoma

Thymoma

Dementia, personality change, chorea,

ataxia, neuropathy

Amphiphysin Small cell carcinoma

Breast adenocarcinoma

Dementia, myelopathy, neuropathy

GAD None

Thymoma

Breast adenocarcinoma

Stiff-person syndrome, ataxia, brainstem

encephalitis, ophthalmoplegia,

parkinsonism, diabetes (DM-1)

Select Onconeural Antibodies

Adapted from McKeon and Pittock, Acta Neuropathol, 2011.

Antibody Associated Cancer Symptoms

(other than seizures / limbic encephalitis)

VGKC-

complex*

None

Small cell carcinoma

Executive dysfunction, personality changes,

brainstem encephalitis, myoclonus (CJD-like

picture), neuropathy, hyponatremia

NMDA None

Ovarian teratoma

Psychosis, extrapyramidal disorders (e.g.,

choreoathetosis), dysautonomia

AMPA Thymic, Lung, Breast −

GABA-B Neuroendocrine tumors

incl. small cell carcinoma

Orolingual dyskinesias

Select Neuronal Membrane Antibodies

Adapted from McKeon and Pittock, Acta Neuropathol, 2011.

*multiple antibody targets in this complex (LGI-1, CASPR2, Contactin-2)

Two Key Antibodies

• VGKC-complex

– associated with hyponatremia

– LGI-1 subtype is associated with faciobrachial

dystonic seizures (with or without EEG correlate)

– may mimic CJD

• NMDA-receptor

– seen with or without ovarian teratoma

– can have choreoathetosis, dysautonomia

Treatment

• No controlled trials, no strong evidence basis

• First line– find / treat cancer

– IV Ig OR IV methylprednisolone daily x3-5 days

– continue weekly for 6-12 weeks

– plasma exchange used if severe symptoms

• If successful– gradual taper + addition of mycophenolate or

azathioprine

• If failed– consider cyclophosphamide, rituximab

Brain Tumors and Epilepsy

Sources:

Glantz et al, Neurol, 2000

Wyllie’s Treatment of Epilepsy, 2011

What tumors are epileptogenic?

• Adult-onset

• Lower grade tumors

• Tumors close to cortex or sensitive networks

(hippocampal, primary motor)

• Parietal tumors have strongest association

with seizures, followed closely by temporal

Tumor pathology and seizures

• Nearly 100% of dysembryoplastic neuro-epithelial tumors (DNET) have seizures

• 75-90% of gangliogiomas and astrocytomas

• 30-60% of meningiomas and GBMs

• <20% of primary CNS lymphomas

• Hypothalamic hamartomas – gelastic seizures

Why do tumors cause seizures?

• Peritumoral, non-neoplastic tissue often

causes seizures (tumor core often silent,

necrotic)

• Genetic factors - for example, LGI1

– tumor-suppressor gene that is absent in GBM

– mutation causes autosomal dominant lateral

temporal lobe epilepsy (with auditory features)

Treatment

• Must balance tumor treatment goals with

epilepsy treatment goals

– seizure freedom is a goal with operable tumors

– first-line anticonvulsants fail in 60-70% of patients

• Older drugs can interact with chemo and

increase risk of bone marrow suppression

• Valproate may have an intrinsic anti-tumor

effect (inhibits histone deacetylase)

Prophylaxis

• NO strong evidence that anticonvulsants can

prevent first seizure in a known brain tumor

• AAN guidelines against their use in patients

who never had a seizure

• Can be given for the first week postop, but

should not be continued

Surgical Evaluation

• Is this “tumor surgery” (curative) or “epilepsy

surgery” (palliative)?

• Poor prognostic factors

– longer epilepsy duration

– low grade tumor

– seizure at onset of tumor diagnosis

– subtotal resection (e.g., positive margins)

Surgical Evaluation

• Imaging alone should not guide surgery

• Assess peritumoral or even distant

epileptogenic focus (may need invasive EEG)

• Assess for dual pathology (hippocampal sclerosis and

tumor); consider resecting both

• Functional mapping (electrocorticography, fMRI) is

important, if tumor is near eloquent cortex

Malformations of Cortical

Development

Sources:

Blumke et al, Epilepsia, 2011

Leventer et al, Dialogues Clin Neurosci, 2008

Krsek et al, Ann Neurol, Jun 2008

Lerner et al, Epilepsia, Jun 2009

Wyllie’s Treatment of Epilepsy, 2011

Malformations of Cortical Development

(MCDs)

• Cortical neurons and glia originate from

germinal matrix (must develop AND migrate)

• Any disruption in development = MCDs

– normal cells in the wrong place

– abnormal cells in the correct place

Polymicrogyria (PMG)

Source: www.germaco.net/pmg_gb.html

Polymicrogyria (PMG)

• Excessive, small convolutions/gyri

• Is a descriptive term, assoc. with many syndromes

• bilateral perisylvian polymicrogyria syndrome

– bihemispheric pre- and post-central PMG

– oromotor dysfunction (tongue, face, pharyngeal, and

speech difficulties)

– seizures

– aphasia

Schizencephaly (SCZ)

Source: http://emedicine.medscape.com/article/413051-overview

Schizencephaly (SCZ)

• Parenchymal clefts from lack of cortical development

– schizencephaly = grey matter along cleft (often PMG)

– porencephaly = white matter along cleft

• deMorsier syndrome

– SCZ

– agenesis of septum pellucidum

– optic nerve hypoplasia

– hypopituitarism

Hemimegalencephaly

Source: http://radiopaedia.org/articles/emimegalencephaly

Hemimegalencephaly

• Triad of intractable partial seizures in infancy,

hemiparesis, and developmental delay

• Variable pathology, including other MCDs

– often isolated

– associated with tuberous sclerosis, neurofibromatosis,

linear nevus sebaceous syndrome, hypomelanosis of Ito

• May need functional hemispherectomy

Subcortical Band Heterotopia

Source: radiopaedia.org/articles/band-heterotopia

Subcortical Band Heterotopia

• “Double cortex” or “subcortical laminar heterotopia”

• Associated with DCX gene mutation (X-linked)

• Milder symptoms

– mild developmental delay

– seizures often delayed until teenage years

Lissencephaly

Source: http://radiopaedia.org/cases/agyria-pachygyria

Lissencephaly (LIS)

• “Smooth brain”

• Developmental delay, hypotonia, spasticity, seizures (esp.

epileptic spasms), and difficulty feeding

• Classical (autosomal) forms

– deletion of LIS1 gene (17p)

– LIS more severe anteriorly

• X-linked forms

– DCX mutation can cause SBH or LIS

– LIS more severe posteriorly

Doublecortin (DCX)

DCX mutation

(Xq22.3-q23)

LIS

SBH

Periventricular Nodular

Heterotopia (PVNH)

Source: http://www.gfmer.ch/genetic_diseases_v2/gendis_detail_list.php?cat3=591

Periventricular Nodular

Heterotopia (PVNH)

• Periventricular gray matter (failed migration)

• Bilateral PVNH is associated with the FLNA

(filamin A) gene at Xq28 (usu. lethal in males)

Subependymal Nodules?

Tuberous SclerosisPeriventricular

Nodular Heterotopia

smaller larger

less in numbermore in number, often

bilateral

heterogeneous homogeneous

calcified not calcified

white matter intensity

on MRI

gray matter intensity on

MRI

Focal Cortical Dysplasia (FCD)

• Typically has refractory partial seizures

• Typical MRI findings

– blurred gray-white junction

– cortical thickening

– “transmantle sign”: abnormal T2 signal extending from cortex to the

superolateral margin of the lateral ventricle

Source: Blumcke et al, Epilepsia, 2011

FCD types and prognosis

• Proposed classification system (ILAE task force*)

– type I – abnormal cortical lamination/layering

– type II – dysmorphic neurons (+ balloon cells in Type IIb)

– type III – associated lesions (e.g., hippocampal sclerosis, tumors,

vascular malformations)

• “Milder” type often has normal MRI (may be found on

interictal PET or SPECT)

• “Severe” pathology (Type IIb) may

have better prognosis – easier to

find on MRI and resect

Source: Lerner et al, Epilepsia, Jun. 2009

*Source: Blumcke et al, Epilepsia, 2011

Post-traumatic Epilepsy

Sources:

Chang and Lowenstein, Neurol, 2003

Schierhout and Roberts, Cochrane review, 2010

Wyllie’s Treatment of Epilepsy, 2011

Early Seizures After Head Trauma

• Early seizures = within first week

• 10% will develop late seizures (multivariate

analysis has shown that early seizures are

predictive but not an independent risk factor)

• Early status has higher risk for late seizures

Early Seizures After Head Trauma

• Strong evidence for prophylaxis in adults with

severe brain injury for the first week only

– Cochrane review – NNT is 10

– AAN recommendations – phenytoin x 1 week

• No evidence that prevention of early seizures

prevents late seizures / epilepsy

Late Seizures After Head Trauma

• Late seizures = epilepsy

• Only one unprovoked late seizure necessary

for diagnosis (recurrence risk is 86% in 2 yrs)

• 70-80% develop epilepsy within 2 years

• Risk declines after that, but epilepsy can start

> 15 years later

Severity of Head Trauma

• Early seizures PLUS moderate/severe trauma

• Mild: LOC < 30 min, no skull fracture

• Moderate: LOC 0.5-24 hrs, no parenchymal injury

• Severe: LOC > 24 hrs, contusion, ICH, or dural penetration

Mild Head Trauma

• May have higher association with psychogenic

non-epileptic events (PNES)

• Head trauma is a risk factor for both epilepsy

and PNES (and PTSD)

Workup

• Imaging may be misleading

– vulnerable networks are preferentially injured (hippocampus, temporal and frontal poles)

– epileptogenic focus may be distant from original injury site

• EEG may be misleading

– in first month after injury, may not predict development of epilepsy / late seizures

– presence of interictal epileptiform discharges may confound a diagnosis of PNES

Treatment considerations

• Seizure-free rates lower (25-40%)

• Hippocampal sclerosis can be post-traumatic,

esp. if trauma occurred before 5 years of age

• Seizure-free rates lower after temporal

lobectomy, but chances of class I outcome is

still up to 60%

Stroke and Epilepsy

Source:

Wyllie’s Treatment of Epilepsy, 2011

Pediatric Stroke

• Neonatal stroke

– Usually large vessel arterial disease

– Up to 80% have seizure as presenting symptom

• Childhood stroke

– Usually small vessel arterial disease

– Up to 30% have seizure as presenting symptom

• Epilepsy risk is approximately 15-25%

Adult Stroke

• Post-stroke seizures: 7-11% incidence

– Acute symptomatic seizures (within 24 hrs)

– Early seizure (within 1 week)

– Late seizure / epilepsy (after 1 week)

• Post-stroke epilepsy: 2-4% prevalence

– High recurrence after first late seizure (50-70%)

– Consider treatment after first late seizure

Predictors of Post-stroke Epilepsy

• Cortical location

• Stroke severity (exam / NIHSS)

• Hemorrhage

• PLEDs/LPDs may be predictive (uncommon)

• Focal slowing is not predictive

References

Blümcke I, Thom M, Aronica E, Armstrong DD, Vinters HV, Palmini A, Jacques TS, Avanzini G, Barkovich AJ, Battaglia G, Becker A, Cepeda C,

Cendes F, Colombo N, Crino P, Cross JH, Delalande O, Dubeau F, Duncan J, Guerrini R, Kahane P, Mathern G, Najm I, Ozkara C, Raybaud C,

Represa A, Roper SN, Salamon N, Schulze-Bonhage A, Tassi L, Vezzani A, Spreafico R. The clinicopathologic spectrum of focal cortical

dysplasias: A consensus classification proposed by an ad hoc Task Force of the ILAE Diagnostic Methods Commission. Epilepsia. 2011

Jan;52(1):158-74

Britton JW. Autoimmune Epilepsy. J Kiffin Penry Epilepsy Minifellow Symposium XXV, AES Annual Meeting, San Diego, CA. 3 Dec 2012.

Chang BS and Lowenstein DH, Practice parameter: Antiepileptic drug prophylaxis in severe traumatic brain injury. Neurol. 2003,60:10-16.

Glantz MJ, Cole BF, Forsyth PA, Recht LD, Wen PY, Chamberlain MC, Grossman SA, Cairncross JG. Practice parameter: Anticonvulsant

prophylaxis in patients with newly diagnosed brain tumors. Neurol. 2000;54;1886-1893.

Irani SR, Bien CG, Lang B. Autoimmune epilepsies. Curr Opin Neurol. 2011,24:146-53.

Krsek P, Maton B, Korman B, Pacheco-Jacome E, Jayakar P, Dunoyer C, Rey G, Morrison G, Ragheb J, Vinters HV, Resnick T, Duchowny M.

Different features of histopathological subtypes of pediatric focal cortical dysplasia. Annals of Neurology. 63(6):758-69, 2008 Jun.

Lerner JT, Salamon N, Hauptman JS, Velasco TR, Hemb M, Wu JY, Sankar R, Donald Shields W, Engel J Jr, Fried I, Cepeda C, Andre VM, Levine

MS, Miyata H, Yong WH, Vinters HV, Mathern GW. Assessment and surgical outcomes for mild type I and severe type II cortical dysplasia:

a critical review and the UCLA experience. Epilepsia. 50(6):1310-35, 2009 Jun.

Leventer RJ, Guerrini R, Dobyns WB. Malformations of cortical development and epilepsy. Dialogues in Clinical Neuroscience. 10(1):47-62,

2008.

McKeon A, Pittock SJ. Paraneoplastic encephalomyelopathies: pathology and mechanisms. Acta Neuropathol. 2011,122:381–400.

Quek AM, Britton JW, McKeon A, So E, Lennon VA, Shin C, Klein C, Watson RE Jr, Kotsenas AL, Lagerlund TD, Cascino GD, Worrell GA, Wirrell

EC, Nickels KC, Aksamit AJ, Noe KH, Pittock SJ. Autoimmune epilepsy: clinical characteristics and response to immunotherapy. Arch

Neurol. 2012 May,69(5):582-93.

Schierhout G, Roberts I. Antiepileptic drugs for preventing seizures following acute traumatic brain injury. Cochrane review, 2010.

Schmitt SE, Pargeon K, Frechette ES, Hirsch LJ, Dalmau J, Friedman D. Extreme delta brush: A unique EEG pattern in adults with anti-NMDA

receptor encephalitis. Neurol. 2012 Sep 11;79(11):1094-100.

Wyllie E, Cascino GD, Gidal BE, Gookin HP. Wyllie’s Treatment of Epilepsy: Principles and Practice, Fifth ed. Philadelphia: Lippincott Williams

and Wilkins, 2011.

Self-Assessment Questions

1. A 55 year old man presents with a one month history of progressive cognitive decline and episodes of unresponsiveness. Despite treatment with multiple anticonvulsants, he becomes comatose. On exam, he is noted to have myoclonic jerks. Labs reveal hyponatremia. Which serum antibody is most likely to be positive in his condition?

A. N-methyl-D-aspartate receptor antibody

B. LGI1 antibody (voltage-gated potassium channel complex)

C. Glutamic acid decarboxylase antibody

D.Anti-amphiphysin antibody

2. A 35 year old woman without a history of epilepsy is hospitalized with confusion and psychosis. EEG reveals very frequent partial seizures, which do not stop despite four anticonvulsants. She is noted to have choreiform movements on examination. Which test is most likely to provide a specific diagnosis in her case?

A. PET-CT of abdomen and pelvisB. LGI1 antibody (voltage-gated potassium channel

complex)C. MRI of the brain with contrastD.Continuous EEG monitoring

3. Certain factors are associated with higher epileptogenicity in brain tumors. Which of the following factors is NOT likely to be associated with higher epileptogenicity?

A. Adult onset of brain tumor

B. Tumor situated near the hippocampus

C. Tumor situated near primary motor cortex

D.High grade tumor pathology

4. Which of these tumor types is most likely to be associated with seizures?

A. Primary CNS Lymphoma

B. Dysembryoplastic Neuroepithelial Tumor

C. Meningioma

D.Astrocytoma

5. A patient with a brain tumor has never had a seizure and is requesting anticonvulsant prophylaxis when being admitted for his surgical resection. The most appropriate response is:

A. Anticonvulsant prophylaxis is not recommended before the first seizure, and it is also not recommended perioperatively.

B. Anticonvulsant prophylaxis is not recommended before the first seizure, but it is recommended for the first six months postoperatively.

C. Anticonvulsant prophylaxis is not recommended before the first seizure, but it is recommended for the first one week postoperatively.

D. Anticonvulsant prophylaxis is recommended before the first seizure, and it is also should be continued indefinitely postoperatively.

6. A 4 year old boy has severe oral and facial dysfunction since birth, associated with difficulty feeding. He has intractable partial epilepsy with bihemispheric epileptiformdischarges on EEG. His MRI is shown below. What is his diagnosis?

A. Polymicrogyria

B. Lissencephaly

C. Schizencephaly

D.Pachygyria

7. An 8 year old boy has history of epilepsy and partial blindness. He has a history of events where he feels palpitations, lightheaded, falls down and passes out for 30-45 seconds. An EEG during the event reveals generalized slow activity. MRI shows clefts in the cortical tissue, lined with grey matter. What is the most appropriate test to order in this patient?

A. Video-EEGB. Tilt-table testingC. 24-hour cardiac rhythm monitoringD. Serum cortisol level

8. A 6 month old boy has epileptic spasms, hypotonia, and difficulty feeding. His MRI reveals lissencephaly. Which genetic mutation is also known to be responsible for a milder phenotype, especially in girls?

A. LIS1 on chromosome 17

B. DCX (doublecortin) on the X chromosome

C. FLNA (filamin A) on the X chromosome

D. TSC2 (tuberin) on chromosome 16

9. A 16 year old girl with intractable partial epilepsy has a brain MRI which reveals periventricular (subependymal) lesions. Which of the following features is more likely to suggest periventricular nodular heterotopia, rather than the subependymalnodules of tuberous sclerosis?

A. Unilateral lesion

B. Calcified lesion

C. Homogenous lesion

D.White matter intensity lesion

10. Which of the following statements is NOT true regarding early seizures after traumatic brain injury?

A. Early seizures occur within the first week after injury

B. Early seizures may be associated with increased occurrence of late seizures / epilepsy

C. Early status epilepticus may be associated with increased occurrence of late seizures / epilepsy

D.Early seizures should be treated in order to lower the risk of late seizures / epilepsy

11. Which of the following statements is true regarding seizures after traumatic brain injury?

A. Prophylaxis of seizures should continue for one month after severe brain injury

B. Risk of epilepsy decreases with time after the injury, especially after the first two years

C. At least two late seizures are necessary to diagnose post-traumatic epilepsy and consider treatment

D.A history of mild head trauma and abnormal EEG should warrant anticonvulsant treatment

12. Which of the following statements is true regarding seizures after stroke?

A. Neonatal strokes are more likely to present with focal neurologic deficits rather than seizures

B. Adult onset stroke is more likely to lead to epilepsy as compared to pediatric stroke

C. At least two late seizures are necessary to diagnose post-stroke epilepsy and consider treatment

D.Focal slowing on EEG is not predictive of epilepsy after stroke

Answers

1. B

2. A

3. D

4. B

5. C

6. A

7. D

8. B

9. C

10.D

11.B

12.D